Liver Cancer Treatment

If you, or someone you know, was recently diagnosed with a liver tumor, you may have heard talk about a new type of cancer treatment called histotripsy.

But what is histotripsy? How does it work? Is it only for patients with liver cancer? And, how do you know if you’re a good candidate for it?

Read on to get answers to these questions and more.

What is histotripsy?

Histotripsy is a new technology that was approved in 2023 by the Food and Drug Administration (FDA) for the treatment of liver tumors. It uses focused ultrasound energy to destroy tumors non-invasively — that is, without making any surgical cuts.

How does histotripsy work?

Histotripsy works through a process called cavitation, or the creation of air pockets in a particular substance. The focused energy created by the ultrasound machine generates enough force to pulverize matter — in this case, liver tumor tissue. It also creates a “bubble cloud” in the process, which shows us that the energy has reached the level necessary to destroy tumor cells.

Patients receiving histotripsy are given general anesthesia so we can control their breathing and minimize movement of the targeted tumor(s). Then, they’re securely positioned on the operating room table and the equipment is situated over them. Doctors then program the robot to deliver the planned treatment. Once the machine is activated, the procedure itself may take anywhere from 10 to 50 minutes per tumor. The focused energy travels through the body to its targeted location and is automatically delivered.

Is histotripsy used exclusively to treat liver cancer?

Yes. At this time, histotripsy is only approved to treat liver cancers. However, it can be any type of liver tumor, whether it is a primary tumor (i.e. a tumor that started in the liver, such as hepatocellular carcinoma or cholangiocarcinoma) or another type of cancer that metastasized, or spread, to the liver.

Histotripsy is being tested for tumors in other organs in clinical trials but is not currently approved for the treatment of tumors outside the liver.

Hepatocellular carcinoma (HCC) is the most common type of liver cancer, but it can be difficult to treat. It’s often not caught until its later stages, and it occurs most frequently in people with chronic liver conditions, such as cirrhosis caused by hepatitis B or hepatitis C. For some of these patients, surgery is not an option, and they have to consider other treatment types.

Two UT MD Anderson investigators have spent much of their careers researching how to help patients with hepatocellular carcinoma live longer — and they recently unlocked a new treatment for patients across the globe.

Armeen Mahvash, M.D., a professor of Interventional Radiology who treats patients with radioembolization and conducts clinical research, and S. Cheenu Kappadath, Ph.D., a professor of Imaging Physics who is an expert in patient imaging and radiation dosimetry, knew that a procedure called Y90-radioembolization could kill the cancer and yield durable responses.

But the results hadn’t been replicated in nationwide or multi-center clinical trials, and that was preventing the treatment from becoming widely accessible to patients beyond UT MD Anderson.

That is, until recently.

In July 2025, they shared the interim results of DOORwaY90, a clinical trial for which they were co-national principal investigators (PIs). It demonstrated that this treatment was exceptionally successful in treating unresectable hepatocellular carcinoma. All patients in the DOORwaY90 clinical trial had 100% tumor control, and no progression of the tumor could be seen on any scans through one year of follow-up. These results were so strong that the Food and Drug Administration (FDA) gave approval for the use of SIR-Spheres as a first-line treatment against unresectable and unablatable hepatocellular carcinoma tumors.

“This is really opening the door for our patients. It’s truly practice-changing work,” says Mahvash.

Developing a new treatment for hepatocellular carcinoma

Years of prior clinical data demonstrated that Y-90 wasn’t consistently effective for HCC patients. But then DOORwaY90 emerged, showing overwhelmingly positive results.

What changed?

Mahvash and Kappadath knew the difference in clinical outcomes between their work and those at other hospitals: the precise delivery of the appropriate amount of radiation to the correct disease location(s) in the liver. In other words, patient-specific dosimetry and targeted delivery.

Previous studies and other clinical practices had not consistently accounted for these considerations, but at UT MD Anderson, it had been a critical part of radioembolization treatment planning for over a decade.

In the summer of 2023, they published the results of the RAPY90D trial – a single-center prospective study demonstrating some success in using Y-90-glass radioembolization in patients with HCC. This brought them one step closer to bringing this treatment to more patients. Now they could use this study as the model upon which they could build the next clinical trial. But this trial would be larger and include more treatment centers.

From the start, DOORwaY90 was different from many other trials. It was known as an investigator-initiated trial, or IIT, meaning it was developed wholly by the PIs — not a pharmaceutical or medical device company — and then taken to other centers. This is not the usual path for most multi-center clinical trials.

Before the trial began, Mahvash and Kappadath also recognized that consistent treatment planning and patient management were essential to the success of a prospective interventional trial. In order to maximize the chance for success, they taught investigators at each of the participating hospitals across the country how to perform patient imaging and its proper use for treatment planning dosimetry for curative response. They started with 65 patients. Eventually, the study grew to include 100 patients across 18 U.S. centers. The difference was remarkable.

Benefits of Y90 for HCC patients

During the Y90 procedure, targeted delivery of SIR-Spheres — tiny, radioactive beads made of resin — is administered through the hepatic artery to the liver cancer cells at the appropriate radiation dose. Using SIR-Spheres — as opposed to other types of radioactive beads that had been used in the past — offered other benefits as well. They deliver up to 40 times more radiation than conventional cancer radiation therapy, which uses a machine to aim high-energy radiation beams from outside the body into the liver. 

Conventional radiation is also given five days a week for several weeks. SIR-Spheres are typically delivered in one session. The beads continue to release radiation over the course of two weeks, gradually decreasing to insignificant levels, with few side effects.  

Doctors know that they’ve hit their target almost immediately after administering the beads. Patients can go home a few hours after the treatment is delivered, and they leave knowing that their tumor has been hit and they’ll have some sort of positive result. In fact, Mahvash gives each of his patients a video that shows the treatment hitting the tumor.

Patients can generally resume their regular activities within two days. The most common side effect is fatigue — the same as with traditional radiation.  

“This shows that doing better treatment planning will give you outstanding results,” Mahvash says.

‘Only possible here’ can now be possible anywhere

Mahvash first began working with SIR-Spheres nearly 20 years ago. Before that, he had worked as a mechanical engineer, but after just a few years, he experienced what he jokingly calls a “mid-life crisis at 23” and enrolled in medical school. He pursued a residency in radiology and became a fellow at UT MD Anderson.

It was then that he first found SIR-Spheres. He had been looking for his niche and thought technology was interesting. But eventually, he began to hit a wall in his work.

“Not being a physicist, there were parts that were out of my realm,” he says.

Mahvash’s mentor introduced him to Kappadath, a leading physicist with a reputation for incredible accuracy and a deep understanding of imaging. He also happened to have an interest in SIR-Spheres.

Like Mahvash, Kappadath had started his professional career in another field: astrophysics. After getting his Ph.D. in astrophysics and completing a fellowship where he worked on space missions, he decided to explore medical imaging and completed a research fellowship at MD Anderson. Medical physics, with its cutting-edge science and technology and potential for tremendous societal impact, hooked him on the field. He pursued didactic training through MD Anderson UTHealth Houston Graduate School and completed a clinical residency in medical physics to eventually become a faculty member at UT MD Anderson.

Mahvash and Kappadath began working closely together around 2010. Over the course of 15 years, they became the leading global experts in their field in 90Y-radioembolization. They’ve worked on eight clinical trials and published over 50 peer-reviewed articles — all in the field of Y90 radioembolization.

“I really could not have done this without Cheenu,” says Mahvash.             

“It goes both ways,” adds Kappadath.

A new chapter for radioembolization

The FDA approval of SIR-Spheres marks a new chapter for radioembolization as a therapy and for patients with unresectable hepatocellular carcinoma.

Both Mahvash and Kappadath agree that UT MD Anderson was the only place this progress could have been made. It took the right focus on collaboration and team science, coupled with resources, large patient volumes and unique expertise.

“This work was only possible here,” Kappadath says.

Now, these patients might have the chance to undergo a liver transplant. And in addition to transforming the lives of these patients, Kappadath and Mahvash have also changed the way researchers will conduct future studies with this work. They’ve demonstrated that careful delivery of adequate radiation dose to targeted locations after appropriate training and coordination was possible in a large multi-center prospective clinical trial. They have published articles on their methodology and trial design. Newer clinical trials on radioembolization using advanced dosimetry treatment planning can be conducted in a similar way.

Now, Mahvash and Kappadath are continuing to educate teams at cancer centers internationally.

“Stopping with 100 patients is not enough,” Mahvash says. “Stopping with a positive study is not enough."

“We need to be able to treat patients beyond UT MD Anderson and even the United States,” Kappadath adds.

Now, they plan to take the work that was once only possible here and enable it around the world through education and clinical collaboration.

Learn about research careers at UT MD Anderson.

Did you know that the liver is the only internal organ that can regenerate? But it doesn’t grow back like a salamander’s tail. When a portion of the liver is removed, the remaining tissue grows bigger. This process is called hypertrophy.

We spoke with surgical oncologist Ching-Wei Tzeng, M.D., to learn what’s happening when a liver regenerates and what factors can impact success. He shared insights on the phenomenon, including how his team is pioneering a care approach in the United States that anticipates the liver’s ability to bounce back to yield the best results possible for patients with liver cancer.

Let’s start with the basics. What does the liver do?

The liver plays three main roles: It serves as a protein factory, a blood filter and a metabolic processor.

The liver produces important proteins that work to balance the thickness of your blood. If the liver isn’t functioning properly, such as from not getting the right nutrients or because of damage like cirrhosis or surgery, your blood may become too thin. With thin blood, you’re more likely to bruise and/or bleed from something as simple as brushing your teeth or shaving.

You can also think of the liver as a water filter. It cleans the huge volume of blood that flows from the gastrointestinal tract back to the heart. If the liver is damaged, fluid can get backed up and lead to a bloated belly.

Lastly, the liver supports metabolic processing. It creates bile that aids food digestion and that helps the body absorb medication.

We often associate liver dysfunction with yellow skin, but that’s not always the case. If one or all of these functions aren’t fulfilled, it’s considered liver failure. And it’s not always apparent by a person’s outward appearance.

What’s happening when the liver regenerates?

Anytime the blood flow is reduced to one part of the liver, the liver will compensate and get bigger if the remaining part is healthy. The cells that grow bigger or hypertrophy are immature, so they don’t have the full function of the mature liver cells yet. But over time – in many cases, in just a few days – they mature and work just as well as the cells that were removed.

Many patients who receive liver cancer surgery see that their remaining liver tissue grows to be almost as big as what was removed only a month after surgery. We see this in patients who have even up to 50% of their liver removed.

We use a test that measures bilirubin levels to help track the function of the liver. When the liver isn’t working properly, bile builds up, and the bilirubin level increases. Once we see that number peak and then start to drop, we know the liver is fine.

We find that for most patients, the liver performs just as well after surgery. It’s as if we didn’t do the surgery. It’s pretty amazing how the liver can bounce back in such a short time.

How does liver regeneration play into the development of a cancer treatment plan?

When planning treatment, we count on the liver to regrow after surgery. With surgery to the lungs, kidney, pancreas, stomach or intestines, we think very carefully about how much tissue we remove because these organs can’t regenerate. There’s no going back.

With liver surgery, we are still very careful, but we plan for some growth to make up for what we remove. We formulate a plan specific to each patient to remove the necessary portions of the liver while leaving a minimum total 30% to grow back. We calculate that using a computer software that measures the size of the liver in relation to a patient’s body size.

We are also careful to remove only what is necessary. That's important for patients’ quality of life. Also, if the liver cancer comes back, we want to ensure a patient has plenty of liver to take more chemotherapy, if necessary, or even have surgery again. We're not just getting rid of cancer today. We're trying to set up patients to be strong should they ever face a diagnosis again.

What research is being done surrounding liver regeneration and cancer?

For the past two decades, MD Anderson has been the leading group in the United States to study preoperative portal vein embolization (commonly referred to as PVE) to grow the liver before surgery. The approach was originally developed in Japan.

About a month before surgery, we deliver small particles to the portion of the liver that we plan to remove to block the blood flow. It helps to redirect the blood to the healthy portion of the liver, which can help it grow ahead of surgery. By growing the healthy portion of the liver, we can hit the 30% mark. It’s amazing because we’re able to offer life-saving liver surgery to patients who previously weren’t eligible.

Request an appointment at MD Anderson online or by calling 1-877-632-6789.

If you’ve been told you need a liver biopsy, you might have some questions. What will the liver biopsy reveal? Will the procedure hurt? How long will it take to recover? 

Read on to find the answers to these and eight other questions patients ask me about liver biopsies.

What is a liver biopsy?

A liver biopsy is a procedure in which a doctor extracts a small amount of tissue from that organ using a needle and sends it off for examination under a microscope. 

Why might I need a liver biopsy?

When an ultrasound, CT scan or MRI shows something unexpected in your liver that cannot be explained based on imaging alone, a biopsy can help us obtain an accurate diagnosis — whether that turns out to be liver cancer, a benign condition or something else entirely. 

If a radiologist sees something suspicious in your liver on imaging and your physician is unsure of the cause, they may order a liver biopsy to figure out what’s going on. In patients with known cancer, the biopsy of cancerous lesions in the liver may also help guide treatment by looking for certain mutations. 

Are there different kinds of liver biopsies?

Yes. At MD Anderson, our interventional radiologists perform about 140 image-guided liver biopsies per month. We use ultrasound, CT or MRI imaging during biopsy procedures to help us determine the best place to insert the needle and collect samples.

Most liver biopsies are performed targeting a specific lesion or abnormality. The rest are non-targeted, or not taken from any particular lesion within the liver. A fair number of liver biopsies are performed for reasons other than a cancer diagnosis. 

Aside from liver cancer, what else can a liver biopsy detect?

Here are some conditions that a liver biopsy may reveal:

• abscess: a pus-filled pocket often caused by infection
• autoimmune disorders: includes inflammatory conditions such as auto-immune hepatitis
• cholangitis: inflammation of the bile ducts, which can be due to infection or inflammatory conditions like primary sclerosing cholangitis (PSC)
• cirrhosis: scar tissue in the liver
• cyst: a fluid-filled sac
• fatty liver disease: a build-up of fat within liver tissue; often seen with excess body weight
• focal nodular hyperplasia (FNH): a benign, or non-cancerous, lesion
• hemangioma: an abnormal collection of blood vessels that can mimic cancer on imaging
• hepatic adenoma: another type of benign tumor; uncommon
• infection
• inflammation 

Keep in mind this isn’t an all-inclusive list; sometimes there are other things that a liver biopsy may reveal. 

We also perform liver biopsies on patients who are in active cancer treatment because some therapies — such as chemotherapy and immunotherapy — can affect the liver. We monitor those patients’ liver function with blood tests, so we can quickly address any problems.

How long does a liver biopsy take?

The procedure itself usually takes 20 to 30 minutes, but sometimes it can take an hour or more. Depending on the complexity of the procedure, it could take as long as 45 to 90 minutes.

What are the risks of a liver biopsy?

The main risk is bleeding. We do everything we can to mitigate that risk and ensure patients can safely tolerate the biopsy. We use small needles specifically designed for biopsies. We typically ask patients taking blood thinners to stop these medications before a procedure. We also obtain bloodwork before any liver biopsy to assess clotting function and confirm that minimum parameters are met to allow for a safe procedure. 

In most situations, bleeding due to a liver biopsy is minimal and resolves on its own. Rarely, additional procedures may be needed to stop the bleeding. 

Another risk is pain. We may need to pass the needle in between ribs to access the liver, and there are many nerves there. In addition, the liver surface can be sensitive and may be an additional source of pain. Soreness after a liver biopsy can last for a few days. Most people will not have too much pain, though, and it’s easily treatable with over-the-counter pain relievers, such as ibuprofen or acetaminophen.

Infection is an additional risk, though it’s very uncommon.

Will I have to be put to sleep for a liver biopsy?

Not usually. Most patients only need local anesthetic and intravenous sedation to stay comfortable and relaxed during the procedure. Some people might need slightly deeper sedation than others, but it’s uncommon to need general anesthesia for a liver biopsy. The sedation needed for a liver biopsy may be administered by the Interventional Radiology team or a dedicated anesthesia team.

How painful is a liver biopsy?

The combination of local anesthetic and sedation usually keeps the process of getting to the liver itself fairly painless. Some people report feeling a little pain as the needle goes into the liver.  That’s why a little soreness is common afterward. 

Severe pain is unusual, though, and it can be a sign of something more serious, such as internal bleeding. In the rare cases when someone has a lot of pain after a liver biopsy, we will do a thorough examination, which may include additional ultrasound or CT imaging, to make sure we are not missing anything. 

Is a liver biopsy considered a serious procedure?

Any procedure involving a major internal organ is serious by definition. The risk of any procedure is never zero. But liver biopsies are considered minimally invasive procedures that are safe with a relatively low rate of adverse events.

How long do you have to stay in the hospital after a liver biopsy?

The vast majority of liver biopsies are performed in outpatient facilities, and patients go home the same day. We usually monitor you afterward for at least three hours. You will be asked to stay in bed and not move around too much. This is usually not a problem, as most people are still tired from the sedation.

How long does it take to fully recover from a liver biopsy?

Patients can usually return to their desk jobs or those that don’t require any physical labor the next day. We advise patients to avoid heavy lifting for at least a couple of weeks. After that, they can return to their normal activities.

Zeyad Metwalli, M.D., is an interventional radiologist who specializes in minimally invasive, image-guided liver and vascular interventions.

Request an appointment at MD Anderson online or call 1-877-632-6789.